Serial Magnetic Resonance Imaging in Active Surveillance of Prostate Cancer: Incremental Value

Abstract

Purpose: We assessed whether changes in serial multiparametric magnetic resonance imaging can help predict the pathological progression of prostate cancer in men on active surveillance.

Materials and methods: A retrospective cohort study was conducted of 49 consecutive men with Gleason 6 prostate cancer who underwent multiparametric magnetic resonance imaging at baseline and again more than 6 months later, each followed by a targeted prostate biopsy, between January 2011 and May 2015. We evaluated whether progression on multiparametric magnetic resonance imaging (an increase in index lesion suspicion score, increase in index lesion volume or decrease in index lesion apparent diffusion coefficient) could predict pathological progression (Gleason 3 + 4 or greater on subsequent biopsy, in systematic or targeted cores). Diagnostic performance of multiparametric magnetic resonance imaging was determined with and without clinical data using a binary logistic regression model.

Results: The mean interval between baseline and followup multiparametric magnetic resonance imaging was 28.3 months (range 11 to 43). Pathological progression occurred in 19 patients (39%). The sensitivity, specificity, positive predictive value and negative predictive value of multiparametric magnetic resonance imaging was 37%, 90%, 69% and 70%, respectively. Area under the receiver operating characteristic curve was 0.63. A logistic regression model using clinical information (maximum cancer core length greater than 3 mm on baseline biopsy or a prostate specific antigen density greater than 0.15 ng/ml(2) at followup biopsy) had an AUC of 0.87 for predicting pathological progression. The addition of serial multiparametric magnetic resonance imaging data significantly improved the AUC to 0.91 (p=0.044).

Conclusions: Serial multiparametric magnetic resonance imaging adds incremental value to prostate specific antigen density and baseline cancer core length for predicting Gleason 6 upgrading in men on active surveillance.

Keywords: magnetic resonance imaging; prostatic neoplasms; watchful waiting.

Figure 1

Flowchart for study inclusion

Figure 2

Example of progression of low grade prostate cancer in 65-year-old man on AS. At baseline axial T2-weighted image (A) demonstrates hypointense lesion in right apical peripheral zone. Diffusion weighted image (B) indicates ADC of 1,128. Overall suspicion score is 3. MR-US fusion biopsy (C ) revealed Gleason 3 + 3 PCa in target (D). After 26 months index lesion appears increased in size (E ) and ADC has decreased to 916 (F). Overall suspicion score of 4 was assigned. Repeat targeted biopsy (G) revealed Gleason 3 + 4 PCa (H ). Lesion fulfills 2 of 3 MRI progression criteria (increase in suspicion score and decrease in ADC).